Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0312, written 22 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Aug 2023 |
|---|---|
| Reference | 2023-0312 |
| Deceased | Audrey King |
| Coroner | Guy Davies |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: PUBLIC REGULATION 28: REPORT TO PREVENT FUTURE DEATHS IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF AUDREY KING REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Officer Royal Cornwall Hospital Trust (RCHT) 1 CORONER I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] 3 INVESTIGATION and INQUEST On 21 November 2022 I commenced an investigation into the death of Audrey King. The investigation concluded at the end of the inquest on 7 August 2023. The medical cause of death was found as follows 1a Ischaemic stroke 1b Atrial Fibrillation II Femoral Hernia repair (Operated) The four questions - who, when, where and how – were answered as follows … Audrey KING died on 15 November 2022 at Royal Cornwall Hospital Truro Cornwall from a stroke following an operation, against a background of atrial fibrillation in which anti-coagulant medication was not re-started which likely contributed to the stroke. The conclusion was as follows Audrey died from complications following necessary surgery contributed to by not re-starting anti-coagulant medication after the operation. 1 Information Classification: PUBLIC 4 CIRCUMSTANCES OF THE DEATH Audrey had a previous medical history which included Atrial Fibrillation (AF), which was medicated by an anti-coagulant, apixaban, to reduce the risk of a stroke. On 6 November 2022, Audrey was admitted to RCHT with abdominal pain secondary to femoral hernia obstruction. The apixaban was suspended pending surgery. Audrey underwent surgery for femoral hernia repair, that same day, 6 November 2022. The operation was uneventful. On 9 November 2022 the eldercare consultant reviewed Audrey. The review notes were handwritten on paper medical notes. The eldercare consultant recommended that the surgical team restart Apixaban as soon as safe post operatively. The court heard evidence that the NICE guidance on this subject states Stroke risk associated with atrial fibrillation; Post procedure with immediate and complete haemostasis NOACs can generally be resumed 6–8 h after the end of the intervention. Some surgical interventions carry increased bleeding risk in which case resume anticoagulation 48–72 h post procedure but at the earliest opportunity The apixaban was not restarted. On 11 November 2022 Audrey had a severe stroke secondary to AF. Audrey died as a result of this complication four days later. The court found that whether and when to re-start the apixaban was a decision for the surgical team. The court heard that on the consultant surgeon’s ward round his junior doctor colleague was briefing him, this included reference to the eldercare review paper notes. The junior doctor went through a number of aspects regarding care and treatment but did not refer to the recommendation to re-start apixaban. As a result, the consultant surgeon did not consider whether or not to re-start the apixaban. The court heard that the eldercare team use paper medical notes whilst the surgical team use a digital system, known as NerveCentre. The consultant surgeon stated that the digital system is easier for the surgical team to read because the consultant surgeons can look at the detail on their phone or iPad. The consultant surgeon considered that the different recording platforms contributed to the error of omission in Audrey’s case. Where an ‘important clinical note’ has been handwritten in the handwritten record there is facility for highlighting this on the ‘ward round’ function on Nerve centre. There was no alert that clinical notes had been handwritten in the written notes following the review by the eldercare consultant on 9th November. The court found that apixaban was prescribed on admission and correctly suspended due to bleeding risk in light of pending surgery. There is no evidence of review of this suspension in either medicines reconciliation (10th November) or in the medical records. The court heard that there is no automatic flag on the Electronic Prescribing Medication Administration (EPMA) requiring review of the ongoing suspension of prescribed medication. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 2 Information Classification: PUBLIC The MATTERS OF CONCERN are as follows. – (1) Inconsistencies in record keeping between specialities. (2) The process for entering an alert in the digital system that clinical notes have been handwritten in the written notes. (3) The absence of an alert on the EPMA requiring review of the ongoing suspension of prescribed medication. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Guy Davies HM Assistant Coroner for Cornwall & the Isles of Scilly 22 August 2023 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Chief Medical Officer’s Office Royal Cornwall Hospital Truro Cornwall TR1 3LJ 12th October 2023 Mr Guy Davies Assistant Coroner for Cornwall and the Isles of Scilly H.M Coroner’s Office Pydar House, Pydar Street Truro, Cornwall TR1 1XU Dear Mr Davies Re: Death of Audrey Joan King – Response to Regulation 28 Report to Prevent Future Deaths I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 22nd August 2023 and received on the 24th August 2023, which was issued at the end of the inquest into the death of Mrs Audrey Joan King on 7th August 2023. I would like to take this opportunity to express my sincerest condolences to the family of Mrs King for their loss. During the course of the inquest, the evidence revealed matters giving rise to concern. These are as follows: Inconsistencies in record keeping by specialities. • • The process for entering an alert in the digital system that clinical notes have been handwritten in the written notes. • The absence of an alert on the EPMA requiring review of the ongoing suspension of prescribed medication. Please find below the response from the Trust and the detail of the actions being taken in relation to each concern. 1 Inconsistences in record keeping by specialities: I note that the Inquest conclusion was that ‘Audrey died from complications following necessary surgery contributed to by not re-starting anti-coagulant medication after the operation.’ , The clinical context that may have led to Mrs King’s death was discussed with Stroke Consultant. Mrs King was known to have atrial fibrillation (AF) and there is a known increased risk of stroke post-operatively. There were clear recommendations which were underlined in Mrs King’s notes by the care of the elderly consultant to re-start apixaban as soon as possible post-operatively. Unfortunately, these recommendations were not followed and could have been one of the factors leading to ischaemic stroke. The Trust is moving towards having all clinical records available electronically and Oracle Health have been awarded the contract for our Electronic Patient Record (EPR) programme. The new EPR will integrate many of our digital and paper-based systems into a single platform, providing a more joined up way of working across our hospitals, improving safety and transforming the way we care. This system is expected to be operational from Spring 2025. Until this is underway, the Trust has taken the decision to advise all specialities to only record inpatient clinical entries in the written paper notes with the exception of EPMA (which is our electronic prescribing system). The only ward exceptions to this are ITU /EPOC (Intensive care and Enhanced peri-operative care unit) which have an electronic record and high staff to patient ratio, there is no duplication and a paper copy is transferred with the patient when they leave ITU/EPOC. This will ensure all specialities undertaking ward rounds will have one set of written notes to review, along with the drugs chart (ePMA) The decision to revert to recording in the written notes was communication to staff and took effect from 08:00 hours on 13 September 2023. The process for entering an alert in the clinical system that clinical notes have been handwritten in the written notes: Please see above, as all specialities have been mandated to only record entries in the written notes, there is no requirement to set up an alert in a clinical system that a written entry has been made in the notes. The absence of an alert on the EPMA requiring review of the ongoing suspension of prescribed medication: The Trust currently uses Careflow Medicines Management systems to support electronic prescribing across most clinical areas. This system does not have the capability to set up an alert if medications are suspended. However, even if this was an option, it would not be 2 considered of benefit due to prescriber alert fatigue which could lead to prescribers ignoring the alert. To put this into context, for example, on 4th September 2023, 9% of medications prescribed for inpatients in the hospital were suspended across the Trust. This equates to 636 suspended items out of a total of 7,010 prescribed medicines for 706 patients. When a drug is suspended it remains on the inpatient chart, with an overlay showing that the drug is suspended (see chart below). When opening the drug chart, the ePMA system gives a clear visual prompt during wards rounds that a current medicine is suspended and this can be re-started if appropriate. Suspended drugs should be reviewed as part of the ward round drug chart review process. As advised above, the system does not have the ability to create a separate alert; however there is a clear visual prompt to alert clinicians that a drug has been suspended and this was in place and in force at the time of Mrs King’s admission. All doctors have a professional responsibility to check written entries, drugs charts and test results on a ward round to ensure they have the full facts before making any clinical decisions. The importance of this is clear in the GMC Guidance, ‘Good Medical Practice’ - Duties of a Doctor and provided over extensive teaching and education with Foundation Year 1 and 2 doctors and IMG induction. The Trust will also run Snapcoms about the importance of checking ePMA along with written entries which will be aimed all staff working within the Trust. I hope that this letter provides both you and Mrs King’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report. 3 Yours Sincerely Chief Medical Officer 4
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